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Purpose: To investigate clinical outcomes, return to sport, and complication rate in patients with an isolated SLAP II-IV tear treated with biceps tenodesis (BT), SLAP-repair (SLAP-R), or both (SLAP-R+BT). Methods: A retrospective analysis of prospectively collected data was performed in patients who underwent surgery between February 2006 and February 2018 for isolated SLAP II-IV lesions with either BT, SLAP-R, or SLAP-R+BT and had minimum 2-year follow-up. Patients were excluded if they were older than 45 years of age, had anterior shoulder instability, rotator cuff tears, glenohumeral osteoarthritis, or concomitant fractures about the shoulder. Clinical outcomes were assessed by the use of the American Shoulder and Elbow Society Score, Single Assessment Numerical Evaluation Score, Quick Disabilities of the Arm, and Shoulder and Hand Score, the General Health Short Form-12 Physical Component, and patient satisfaction. Results: There were 38 shoulders in the isolated BT group with 1 (2.6%) shoulder requiring revision, 13 in the SLAP-R group with no patient requiring revision, and 21 in the SLAP-R+BT group with 2 (9.5%) shoulders requiring revision. Minimum 2-year follow-up was obtained in >85% of each group. Mean age at time of surgery was significantly different between the groups (36.5 years BT vs 27.7 years SLAP-R vs 36.5 years SLAP-R+BT; P = .003). While patient-reported outcomes improved significantly from pre- to postoperatively for the BT (P < .001) and SLAP-R+BT groups (P < .001), they did not significantly improve for the isolated SLAP-R group (P values ranging .635 to .123). The BT and SLAP-R+BT groups showed significant improvement in return to sport pre- to postoperatively whereas the SLAP-R group did not. The SLAP-R+BT group had the most patients reaching minimal clinical important difference, substantial clinical benefit, and patient acceptable symptom state American Shoulder and Elbow Society Score scores; however, this was not statistically significant. Conclusions: SLAP II-IV lesions treated with BT or both SLAP-R+BT demonstrated improved outcomes compared with isolated SLAP-R at minimum 2-year follow-up. Concomitant biceps tenodesis should be considered when performing repair of SLAP II-IV tears. Level of Evidence: III; Retrospective comparative study.

Purpose To perform a systematic review comparing clinical outcomes, radiographic outcomes, and complication rates after acute (surgery ≤6 weeks from injury) versus chronic (surgery >6 weeks from injury) acromioclavicular joint reconstructions for grade III injuries using modern suspensory fixation techniques. Methods We performed a systematic review of the literature examining acute versus chronic surgical treatment of Rockwood grade III acromioclavicular joint separations using the Cochrane registry, MEDLINE database, and Embase database over the past 10 years according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The inclusion criteria included techniques using suspensory fixation, a minimum study size of 3 patients, a minimum follow-up period of 6 months, human studies, and English-language studies. The methodology of each study was evaluated using the Methodological Index for Non-randomized Studies (MINORS) tool for nonrandomized studies and the revised Cochrane risk-of-bias (RoB 2) tool for randomized controlled trials. Results The systematic review search yielded 20 studies with a total of 253 patients. There were 2 prospective randomized controlled trials, but most of the included studies were retrospective. On comparison of acute surgery (≤6 weeks) and chronic surgery (>6 weeks), individual studies reported a range of Constant scores of 84.4 to 98.2 and 80.8 to 94.1, respectively. The ranges of radiographic coracoclavicular distances reported at final follow-up also favored acute reconstructions, which showed improved reduction (9.2-15.7 mm and 11.7-18.6 mm, respectively). The reported complication rates ranged from 7% to 67% for acute reconstructions and from 0% to 30% for chronic reconstructions. Conclusions The ranges in the Constant score may favor acute reconstructions, but because of the heterogeneity in the surgical techniques in the literature, no definitive recommendations can be made regarding optimal timing. Level of Evidence Level IV, systematic review of Level I through IV studies.

Women with a personal history of breast or ovarian cancer who previously had BRCA1/2 testing now have the opportunity for additional genetic risk information through multi-gene panel testing. However, little is known about women's receptivity to further contact and uptake of genetic counseling and updated genetic testing. Utilizing a clinic database to identify potential participants, we prospectively contacted women in the United States with a personal and/or family history of breast or ovarian cancer who had negative BRCA1/2 testing, which was performed primarily between 2011 and 2018. Eligible and interested participants were scheduled for a genetic counseling appointment to discuss updated genetic testing using a multi-gene panel. We attempted to contact 455 participants, screened 203 (45%), and 103 (23%) completed a pre-test genetic counseling visit to discuss updated testing. Of these, 88 participants had updated multi-gene panel testing. Participants had an average age of 59 years, and most (78%) had breast cancer with an average age of 45 at diagnosis. The majority (97%) of participants were white. Of participants who underwent panel testing, 13% (n = 11) had at least one pathogenic variant identified. Most participants (86%) had an out-of-pocket cost of $100 or less for their panel. There is a sizable population of women with a personal and/or family history of breast or ovarian cancer and negative BRCA1/2 test results who would qualify for updated multi-gene panel testing. In our study, 59% of those reached who were eligible completed a pre-test genetic counseling visit. Clinics could consider an outreach program to offer genetic counseling and updated genetic testing. Supports for this type of effort may include coordinators and genetic counseling assistants and an available database with patients' contact information and prior genetic test results. Updated testing allows women more information about their risk and may expand the value of genetic counseling.

Background: Modern rotator cuff repair techniques demonstrate favorable early and midterm outcomes, but long-term results have yet to be reported. Purpose: To determine 10-year outcomes and survivorship after arthroscopic double-row transosseous-equivalent (TOE) rotator cuff repair. Study Design: Case series; Level of evidence 4. Methods: The primary TOE rotator cuff repair procedure was performed using either a knotted suture bridge or knotless tape bridge technique on a series of patients with 1 to 3 tendon full-thickness rotator cuff tears involving the supraspinatus. Only patients who were 10 years postsurgery were included. Patient-reported outcomes were collected pre- and postoperatively, including American Shoulder and Elbow Surgeons (ASES), 12-Item Short Form Health Survey (SF-12), Single Assessment Numeric Evaluation (SANE), shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), and satisfaction. Kaplan-Meier survivorship analysis was performed. Failure was defined as progression to revision surgery. Results: A total of 91 shoulders (56 men, 31 women) were included between October 2005 and December 2009. Mean follow-up was 11.5 years (range, 10.0-14.1 years). Of 91 shoulders, 5 (5.5%) failed and required revision surgery. Patient-reported outcomes for patients who survived were known for 80% (69/86). Outcomes scores at final follow-up were as follows: ASES, 93.1 ± 10.8; SANE, 87.5 ± 14.2; QuickDASH, 11.1 ± 13.5; and SF-12 physical component summary (PCS), 49.2 ± 10.1. There were statistically significant declines in ASES, SANE, and SF-12 PCS from the 5-year to 10-year follow-up, but none of these changes met the minimally clinically important difference threshold. Median satisfaction at final follow-up was 10 (range, 3-10). From this cohort, Kaplan-Meier survivorship demonstrated a 94.4% survival rate at a minimum of 10 years. Conclusion: Arthroscopic TOE rotator cuff repair demonstrates high patient satisfaction and low revision rates at a mean follow-up of 11.5 years. This information may be directly utilized in surgical decision making and preoperative patient counseling regarding the longevity of modern double-row rotator cuff repair.

Purpose To report clinical outcomes following arthroscopic suprascapular nerve (SSN) decompression for suprascapular neuropathy at the suprascapular and/or spinoglenoid notch in the absence of major concomitant pathology. Methods We retrospectively reviewed prospectively collected data of 19 patients who underwent SSN release at the suprascapular and/or spinoglenoid notch between April 2006 and August 2017 with ≥2 years of follow-up. Patients who underwent concomitant rotator cuff or labral repairs or had severe osteoarthritis were excluded. Pre- and postoperative strength and patient-reported outcomes were collected, including the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numerical Evaluation (SANE), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), 12-item Short Form (SF-12), and satisfaction. Complications and revisions were recorded. Results At a mean final follow-up of 4.8 years, pre- to postoperative ASES (64.9 ± 18.7 versus 83.5 ± 23.1; P = .018), QuickDASH (28.7 ± 17.2 versus 12.7 ± 17.1; P = .028), SANE (64.3 ± 16.4 versus 80.8 ± 22.3; P = .034), and SF-12 PCS (41.1 ± 10.8 versus 52.3 ± 5.8; P = .007) scores all significantly improved. Median strength for external rotation improved significantly (4 [range 2 to 5] versus 5 [range 3 to 5]; P = .014). There was no statistically significant improvement in median strength for abduction (4 [range 3 to 5] versus 5 [5]; P = .059). Median postoperative satisfaction was 9 (range 1 to 10), with 8 patients (50%) rating satisfaction ≥9. No complications were observed, and no patients went on to revision surgery. Conclusion Arthroscopic SSN decompression for suprascapular neuropathy at the suprascapular and/or spinoglenoid notch in the absence of major concomitant glenohumeral pathology results in good functional outcomes with significant improvements from before to after surgery. Level of Evidence IV, therapeutic case series.

Acute flaccid myelitis (AFM) is a disabling, polio-like illness mainly affecting children. Outbreaks of AFM have occurred across multiple global regions since 2012, and the disease appears to be caused by non-polio enterovirus infection, posing a major public health challenge. The clinical presentation of flaccid and often profound muscle weakness (which can invoke respiratory failure and other critical complications) can mimic several other acute neurological illnesses. There is no single sensitive and specific test for AFM, and the diagnosis relies on identification of several important clinical, neuroimaging, and cerebrospinal fluid characteristics. Following the acute phase of AFM, patients typically have substantial residual disability and unique long-term rehabilitation needs. In this Review we describe the epidemiology, clinical features, course, and outcomes of AFM to help to guide diagnosis, management, and rehabilitation. Future research directions include further studies evaluating host and pathogen factors, including investigations into genetic, viral, and immunological features of affected patients, host-virus interactions, and investigations of targeted therapeutic approaches to improve the long-term outcomes in this population.

Arthroscopic Bankart repair techniques have evolved from solid anchors, with potential disadvantages such as glenoid rim fractures, anchor migration, and glenohumeral cartilage damage, to bone stock-preserving “soft” all-suture anchors. The aim of this study was to report on clinical short-term outcomes after arthroscopic knotless all-suture Bankart repair in patients with anterior shoulder instability. It is hypothesized that this technique provides good functional outcomes with low rates of re-dislocation and revision. A total of 39 patients with an average age of 28.8 (SD ± 10.5) years were included. The clinical outcome was evaluated at a minimum follow-up of 12 months in 28 of 39 (72%) patients. The American Shoulder and Elbow Surgeons Score (ASES), Single Assessment Numeric Evaluation Score (SANE), Quick Disabilities of the Arm, Shoulder and Hand Score (QuickDASH), the Short Form 12 physical component summary (SF-12 PCS) as well as general patient satisfaction were assessed. Re-dislocation and revision rates were recorded. Postoperatively, one patient (3.6%) re-dislocated his shoulder during a baseball game and required revision surgery with a Latarjet procedure. One patient (3.6%) reported a sensation of instability and 37 of 39 (95%) patients remained stable. At the final follow-up, the mean ASES (p

Fractures of the anteroinferior aspect of the glenoid rim, known as a bony Bankart lesions, can occur frequently in the setting of traumatic anterior shoulder dislocation. If these lesions are large and are left untreated in active patients, then recurrent glenohumeral instability due to glenoid bone deficiency may occur. Therefore, the clinician must recognize these lesions when they occur and provide appropriate treatment to restore physiological joint stability. This article aims to provide an overview focusing on clinical and technical considerations in the diagnosis and treatment of bony Bankart lesions.

Background: Total shoulder arthroplasty (TSA) is an effective procedure for the treatment of glenohumeral osteoarthritis (GHOA) delivering reliable pain relief and improved shoulder function. Abnormal glenoid morphologies are common, and biconcave glenoids are enigmas that have been associated with poor clinical outcomes and implant survivorship. Purpose: To assess the clinical outcome scores of patients who underwent noncorrective, concentric reaming for TSA with biconcave glenoids (B2). We hypothesized that patients with B2 glenoids who underwent TSA with glenoid implantation using noncorrective, concentric reaming would have significant improvements in clinical outcome scores and high implant survivorship. Methods: All patients who underwent anatomic TSA for GHOA with B2 glenoids, performed by a single surgeon, between July 2006 and December 2015 with minimum 2-year follow-up were reviewed. Walch classification was obtained from preoperative imaging (magnetic resonance imaging or computed tomography). Clinical outcome scores were prospectively collected and included American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Single Assessment Numerical Evaluation (SANE) score, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, 12-Item Short Form Health Survey physical component summary (PCS), and patient satisfaction. Clinical failures (revision TSA surgery or conversion to reverse TSA) and complications were reported. Paired t test and bivariate correlations level of significance was set at P = .05. Survivorship analysis with implant failure as an endpoint was done using Kaplan-Meier survival curves. Results: 51 TSA in 49 patients (9 females, 40 males) with primary GHOA with B2 glenoids were performed with a mean age of 64 (range 36-81 years) at the time of surgery. The mean retroversion was 19.1° (range 5.4°-38°), and posterior decentering was 42.0% (range 19.4%-78.5%). At final evaluation, 45/51 anatomic TSAs (88% follow-up) with a mean follow-up of 4.9 years (range 2.0-10.4 years) were assessed. All clinical outcome scores improved significantly pre- to postoperatively: ASES, 52.5 to 79.6 (P < .001); SANE, 52.4 to 74.7 (P < .001); QuickDASH, 39.2 to 19.1 (P = .001); and PCS, 40.9 to 48.9 (P = .001). Median postoperative satisfaction was 9 (range 1-10). There were 2 failures and 4 that required another surgery —subscapularis repair, lysis of adhesions, irrigation and débridement, and one to explore the status of the subscapularis for persistent pain. The implant survivorship rate was 95% at a mean follow-up of 4.9 years. Conclusion: Anatomic total shoulder replacement with minimally noncorrective, concentric reaming in patients with B2 glenoids had significant improvement in clinical outcome scores, high patient satisfaction, and high survivorship in this cohort.

Treatment of severe acromioclavicular joint injuries remains controversial and has evolved over the past 4-plus decades. Although several variations on reconstruction exist, an ideal technique will likely use a combination of coracoclavicular ligament reconstruction with suture backup stabilization, minimal drill holes to reduce the risk of fracture, arthroscopic-assisted guidance for anatomic graft and suture placement in and around the coracoid, and fluoroscopic-aided reduction to ensure an anatomic acromioclavicular joint. The objective of this Technical Note is to describe an arthroscopic-assisted coracoclavicular ligament reconstruction with allograft using fluoroscopically guided and cerclage-controlled anatomic reduction of the acromioclavicular joint.

Background Seymour fractures are important to recognize and treat promptly because injuries may result in growth disturbance, nail deformity, or infection. We hypothesize that the administration of antibiotics within 24 hours of injury will be associated with a decreased rate of infection. Methods Patients younger than 18 years were included if clinical examination and radiographs demonstrated a Seymour fracture. The timing of antibiotic administration and treatment details were reviewed. The presence of superficial infections or radiographic evidence of osteomyelitis was recorded. Results A total of 52 patients with 54 fracture that had greater than 30 days of follow-up and were included in data analysis. The average age at the time of injury was 10.2 years. Thirty-four (63%) of 54 patients were most commonly injured secondary to a crush type mechanism. The overall infection rate was 27.3% (15/54 fractures). Among the 29 fractures that received antibiotics within 24 hours of injury, 2 infections (6.9%) were noted at final follow-up. Delayed administration of antibiotics beyond 24 hours postinjury was observed in 17 fractures and was associated with an increased infection rate of 76.5% (13/17, P = 0.000). Conclusions Early administration of antibiotics within 24 hours of injury is associated with a reduction in the development of infections. Patients with delayed antibiotic administration may be at high risk for early superficial infection or osteomyelitis. This study highlights the importance of early identification and appropriate treatment of Seymour fractures including the prompt administration of antibiotics following injury.

U.S. Department of Energy, Office of Energy Efficiency and Renewable Energy, Geothermal Technologies Office Award Number DE-EE0008106

Proportionality remains a vague concept, in part due to the inherent difficulty of balancing two fundamentally important, but potentially conflicting values, particularly when no recognised method exists to definitively determine where the balance should lie. In the current global climate, privacy has increasingly found itself balanced against the necessity of a wide range of intrusive technological measures judged essential to the state’s fight against terrorism. The range of measures involved can make assessing proportionality complicated, as relying on the proportionality test which isolates and examines a particular legal measure independently, might not adequately identify the total risk presented to an individual’s privacy. In this article, it is proposed that one way of addressing this issue is through turning to the biological concept of the ecosystem for guidance. This concept recognises the existence of a closely interconnected system of actors, engaged in the exchange of information and resources. In particular, it places great importance on the interconnections between the various actors, and the effects one can have on another. This article therefore considers whether this approach can be utilised in order to conduct a more holistic proportionality assessment, and whether it provides a viable method of analysis within law.

Effective use of genetic and genomic data in cancer prevention and treatment depends on adequate communication with patients and the public. Although relevant empirical work has emerged, the scope and outcomes of this communication research have not been characterized. We conducted a comprehensive scoping review of recent published research (2010–2017) on communication of cancer-related genetic and genomic testing (CGT) information. Searches in six databases revealed 9,243 unique records; 513 papers were included. Most papers utilized an observational quantitative design; fewer utilized an experimental design. More attention has been paid to outcomes of CGT results disclosure than to decision making regarding CGT uptake or the process of results disclosure. Psychosocial outcomes were most common across studies. This literature has a strong focus on BRCA1/2, with few papers focused on Lynch syndrome or next-generation technologies. Women, Caucasians, older adults, and those of higher socioeconomic status were overrepresented. Research gaps identified include the need for studies on the process of CGT communication; examining behavioral, decision-making, and communication outcomes; and inclusion of diverse populations. Addressing these gaps can help improve the use of genomics in cancer control and reduce disparities in access to and use of CGT.

Objectives: The presence of glenolabral articular disruption (GLAD) lesions has been shown to be associated with higher rates of recurrent anterior shoulder instability and the need for repeat surgery; however, no series has yet reported clinical outcomes in a GLAD-specific cohort. Further investigation is warranted to characterize the prognosis of GLAD injuries and to identify risk factors associated with inferior outcomes. Purpose: The purpose of this study was to compare clinical outcomes between anterior shoulder instability patients with and without GLAD lesions after undergoing arthroscopic anterior shoulder stabilization and to evaluate potential risk factors that may predispose patients with GLAD lesions to inferior outcomes. Methods: Prospectively collected data was retrospectively reviewed for patients who underwent arthroscopic anterior shoulder instability repair with and without GLAD lesions at a minimum of 2 year follow-up. Consecutive patients who underwent arthroscopic surgery for GLAD lesion were matched to patients who underwent arthroscopic anterior Bankart repair by age, sex, and number of anchors. Patient reported outcomes (PROs) were evaluated pre- and post-operatively, including American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and satisfaction (10-point scale). Recurrent instability, defined as recurrent dislocation, as well as reoperation were analyzed. Patients were asked to report their subjective shoulder stability compared to preoperatively (much better, better, same, worse, or much worse). Additionally, outcome scores were assessed based on GLAD lesion morphology and surgical treatment including lesion thickness (full vs. partial), size (mm3), anchor placement (in the defect vs. outside the defect), and microfracture (performed vs. not performed). Statistical significance was defined as P < .05. Results: A total of 58 patients (29 GLAD, 29 non-GLAD (Bankart only)) with a mean age of 28.5 ± 11.9 years were analyzed at 4.1 ± 1.7 years (range, 2.0-8.2) postoperatively. Seventy-six percent (44/58) of the patients were males and 24% (14/58) were females. Patients in both groups experienced significant improvements in all outcome scores after surgery (P < .05 for all) (Table 1). No significant differences were found in postoperative scores between the GLAD and non-GLAD groups [ASES (94.8 ± 8.5 vs 93.4 ± 14.1), SF-12 PCS (55.5 ± 4.5 vs 54.2 ± 8.5), SANE (90.4 ± 7.7 vs 91.3 ± 15.5), DASH (9.4 ± 15.1 vs 7.0 ± 14.9) ( P > .05 for all)] (Table 2). The median satisfaction for the GLAD and non-GAD groups was 10 (range, 1-10) and 10 (range, 1-10), respectively. Two patients in the GLAD cohort underwent reoperation: 1 for symptoms of instability at 1.5 years and the other for persistent anterior shoulder pain at 1 year post-operatively. No patients in the non-GLAD cohort underwent reoperation. No statistical differences in recurrent dislocation were observed between the GLAD (n=2, 9%) and non-GLAD (n=4, 15%; P = .67) groups; however, a significantly greater proportion of patients in the GLAD group reported worse or much worse (n=11, 50%) shoulder instability after surgery compared to the non-GLAD group (n=1, 3.8%; P=.0004). No significant differences in outcome scores were observed in GLAD patients based on thickness of the lesion, labral advancement into the defect, or treatment with microfracture (P >.05 for all). Additionally, there was no significant association between PROs and GLAD lesion size (P >.05 for all) (Table 3). Conclusions: Patients with GLAD lesions had significantly higher subjective shoulder instability when compared with a matched cohort of non-GLAD (Bankart only) patients. No difference between frank shoulder dislocation was seen. All patients had significant improvements in post-operative outcome scores with high satisfaction. There was no difference in outcomes in those with larger GLAD lesions nor if a microfracture or labral advancement was performed. Anterior shoulder instability patients with GLAD lesions were not found to have inferior outcomes but do have higher subjective instability compared with patients with Bankart only lesions. Longer term studies are necessary to evaluate the risk of arthritic change in those with GLAD lesions. [Table: see text][Table: see text][Table: see text]

Background:Both margin convergence rotator cuff repair (MC-RCR) and superior capsular reconstruction (SCR) result in improved clinical outcomes in the treatment of massive rotator cuff tears (RCTs). The question remains whether it is better to perform MC-RCR using native, albeit occasionally deficient, tissues or to perform primary SCR.Purpose/Hypothesis:To compare the clinical results of MC-RCR versus SCR for the treatment of massive RCTs. It was hypothesized that SCR would yield better outcomes.Study Design:Cohort study; Level of evidence, 3.Methods:Included were patients who underwent arthroscopic MC-RCR or SCR for massive RCTs performed by a single surgeon between 2014 and 2019. MC-RCR was performed if it was technically possible to close the defect; otherwise, SCR was performed. Outcomes were assessed at 6 months and then annually using American Shoulder and Elbow Surgeons; Single Assessment Numerical Evaluation; shortened version of Disabilities of the Arm, Shoulder and Hand; 12-Item Short Form Health Survey Physical Component Summary; and patient satisfaction scores. The minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptom State (PASS) were compared between groups. Revision surgeries and complications were reported.Results:Included were 46 patients in the MC-RCR group (mean age, 59 ± 8 years) and 46 patients in the SCR group (mean age, 57 ± 7 years); 29 patients in each group were available at 2-year follow-up. Preoperative outcome scores were not significantly different between groups. Within groups, all outcome scores improved from pre- to postoperatively ( P < .05), with no significant differences in postoperative scores or patient satisfaction between groups. No significant between-group differences were noted in the percentage of patients who reached the MCID, SCB, and PASS (MCID, 92.3% vs 84.6%; SCB, 80.8% vs 80.8%; and PASS, 66.7% vs 66.7%). SCR had a significantly lower survivorship rate compared with MC-RCR (84.7% vs 100%) ( P = .026).Conclusion:Both MC-RCR and SCR provided similar improvement in outcomes; however, SCR resulted in a significantly lower survivorship rate at 2 years postoperatively. If an RCT is technically repairable, we recommend that it be repaired primarily, even if MC techniques are needed to close the defect. SCR remains a good option for massive RCTs that are not technically repairable.

Mass adoption of renewable heating is essential for achieving Net Zero 2050 emission targets. Rapid decarbonisation of heating could be delivered by 5th generation district heating networks, which share heating and cooling and offer energy, cost and carbon savings. We present an assessment framework for determining the economic, operational, and carbon benefits of heat pump driven energy sharing networks for an urban centre. Our analysis of complementary heating and cooling loads enabled novel identification of the building types which are best suited to thermal energy sharing. An urban street was modelled using Integrated Energy System Virtual Environment software, which produced heating, cooling, and hot water loads. These were implemented into a linear programming cost and carbon optimisation problem, producing operating curves for a pool of de-localised heat pumps under either cost or emission minimalization scenarios. Results show that energy sharing networks may reduce the Levelised Cost of Energy by 69% and carbon emissions by 13% when compared to an electrified non-shared energy system. Based on these findings, a load matrix was constructed to identify which energy loads from different building types can be suitably used for energy sharing. Despite promising cost-savings results, we conclude that low temperature district heating networks have much greater financial benefit when utilising appropriately sized thermal storage and time of use tariffs, rather than energy sharing. However, carbon savings can be made over alternatives, such as natural gas boilers. For developers undertaking a heat network project, the primary goal should be clearly defined as either carbon saving or money-making objective, as these are difficult to achieve synergistically.

Introduction Increased mortality has been demonstrated in older adults with coronavirus disease 2019 (COVID-19), but the effect of frailty has been unclear. Methods This multi-centre cohort study involved patients aged 18 years and older hospitalised with COVID-19, using routinely collected data. We used Cox regression analysis to assess the impact of age, frailty and delirium on the risk of inpatient mortality, adjusting for sex, illness severity, inflammation and co-morbidities. We used ordinal logistic regression analysis to assess the impact of age, Clinical Frailty Scale (CFS) and delirium on risk of increased care requirements on discharge, adjusting for the same variables. Results Data from 5,711 patients from 55 hospitals in 12 countries were included (median age 74, interquartile range [IQR] 54–83; 55.2% male). The risk of death increased independently with increasing age (>80 versus 18–49: hazard ratio [HR] 3.57, confidence interval [CI] 2.54–5.02), frailty (CFS 8 versus 1–3: HR 3.03, CI 2.29–4.00) inflammation, renal disease, cardiovascular disease and cancer, but not delirium. Age, frailty (CFS 7 versus 1–3: odds ratio 7.00, CI 5.27–9.32), delirium, dementia and mental health diagnoses were all associated with increased risk of higher care needs on discharge. The likelihood of adverse outcomes increased across all grades of CFS from 4 to 9. Conclusion Age and frailty are independently associated with adverse outcomes in COVID-19. Risk of increased care needs was also increased in survivors of COVID-19 with frailty or older age.

Posterior shoulder instability is increasingly recognized and diagnosed in young athletes. These patients often present with vague shoulder pain rather than the frank instability commonly seen with anterior instability. Three common causes of posterior shoulder instability are congenital retroversion, a single traumatic event, or repetitive microtrauma with erosive effects. The critical determination when deciding on the appropriate treatment of posterior shoulder instability is the presence and degree of glenoid bone loss. In patients without bone loss, arthroscopic procedures have a high success rate with a failure rate of less than 10% and an 89% return-to-sport rate. The determination of the critical amount of bone loss that would permit an arthroscopic procedure is controversial, but recent reports that attempt to quantify the critical bone loss value posteriorly have ranged from 13.5% to 20%. This Technical Note describes our preferred method of open surgical treatment of posterior shoulder instability with posterior glenoid bone loss using an intra-articular distal tibial allograft., Technique Video Video 1 Step-by-step illustration of an open posterior glenoid reconstruction using an intra-articular distal tibial allograft in a patient with posterior shoulder instability and posterior glenoid bone loss. The procedure is performed on a right shoulder with the patient in the lateral decubitus position. A 12-cm vertical incision is made approximately 2 cm lateral to the perceived glenohumeral joint. Dissection is carried out to expose the posterior glenohumeral joint capsule. The exposed capsule is incised vertically, using a long-handled knife in line with the posterior glenoid rim, to gain exposure to the posterior glenoid. The posterior labrum is then completely excised from the 6 to 9:30 o’clock positions, and the posterior glenoid is decorticated by using a high-speed bone-cutting burr and rongeur. The desired distal tibial allograft is sized and prepared using a distal tibial allograft guide system and prep station (Arthrex, Naples, FL). A 3.5-mm drill is used to create 2 parallel gliding holes in the graft, which is then appropriately positioned on the posterior glenoid and fixated using two 3.5-mm solid cortical screws in a lag by an application technique. Subsequently, the redundant posterior capsule is imbricated and the wound is closed in a layered fashion.

Background: The acromioclavicular (AC) capsule and ligament have been found to play a major role in maintaining horizontal stability. To reconstruct the AC capsule and ligament, precise knowledge of their anatomy is essential. Purpose/Hypothesis: The purposes of this study were (1) to determine the angle of the posterosuperior ligament in regard to the axis of the clavicle, (2) to determine the width of the attachment (footprint) of the AC capsule and ligament on the acromion and clavicle, (3) to determine the distance to the AC capsule from the cartilage border of the acromion and clavicle, and (4) to develop a clockface model of the insertion of the posterosuperior ligament on the acromion and clavicle. It was hypothesized that consistent angles, attachment areas, distances, and insertion sites would be identified. Study Design: Descriptive laboratory study. Methods: A total of 12 fresh-frozen shoulders were used (mean age, 55 years [range, 41-64 years]). All soft tissue was removed, leaving only the AC capsule and ligament intact. After a qualitative inspection, a quantitative assessment was performed. The AC joint was fixed in an anatomic position, and the attachment angle of the posterosuperior ligament was measured using a digital protractor. The capsule and ligament were removed, and a coordinate measuring device was utilized to assess the width of the AC capsule footprint and the distance from the footprint to the cartilage border of the acromion and clavicle. The AC joint was then disarticulated, and the previously marked posterosuperior ligament insertion was transferred into a clockface model. The mean values across the 12 specimens were demonstrated with 95% CIs. Results: The mean attachment angle of the posterosuperior ligament was 51.4° (95% CI, 45.2°-57.6°) in relation to the long axis of the entire clavicle and 41.5° (95% CI, 33.8°-49.1°) in relation to the long axis of the distal third of the clavicle. The mean clavicular footprint width of the AC capsule was 6.4 mm (95% CI, 5.8-6.9 mm) at the superior clavicle and 4.4 mm (95% CI, 3.9-4.8 mm) at the inferior clavicle. The mean acromial footprint width of the AC capsule was 4.6 mm (95% CI, 4.2-4.9 mm) at the superior side and 4.0 mm (95% CI, 3.6-4.4 mm) at the inferior side. The mean distance from the lateral clavicular attachment of the AC capsule to the clavicular cartilage border was 4.3 mm (95% CI, 4.0-4.6 mm), and the mean distance from the medial acromial attachment of the AC capsule to the acromial cartilage border was 3.1 mm (95% CI, 2.9-3.4 mm). On the clockface model of the right shoulder, the clavicular attachment of the posterosuperior ligament ranged from the 9:05 (range, 8:00-9:30) to 11:20 (range, 10:00-12:30) position, and the acromial attachment ranged from the 12:20 (range, 11:00-1:30) to 2:10 (range, 13:30-14:40) position. Conclusion: The finding that the posterosuperior ligament did not course perpendicular to the AC joint but rather was oriented obliquely to the long axis of the clavicle, in combination with the newly developed clockface model, may help surgeons to optimally reconstruct this ligament. Clinical Relevance: Our results of a narrow inferior footprint and a short distance from the inferior AC capsule to cartilage suggest that proposed reconstruction of the AC joint capsule should focus primarily on its superior portion.

Background. Accidental radiation exposure can occur anytime. Biodosimeters help in quantifying the absorbed dose of individuals who are not equipped with personal dosimeters during radiation exposure. The dicentric assay can quantify radiation damage by correlating radiation dose exposure with the frequency of dicentric chromosomes in the peripheral lymphocytes extracted from exposed individuals. Objective. The study aims to present the interim results of the reference dose-response curve for a Philippine radiotherapy facility constructed using a 6MV linear accelerator (ClinacX, Varian). Methods. Samples of peripheral blood from healthy volunteers were irradiated in a customized water phantom of doses 0.10 to 5.0 Gray using a linear accelerator. The irradiated samples were cultured and analyzed following the International Atomic Energy Agency Cytogenetic Dosimetry Protocol (2011) with modifications. Linear-quadratic model curve fitting and further statistical analysis were done using CABAS (Chromosome Aberration Calculation Software Version 2.0) and Dose Estimate (Version 5.2). Interim results of the samples were used to generate these curves. Results. The dose-response curve generated from the preliminary results were comparable to published dose response curves from international cytogenetic laboratories. Conclusion. The generated dose-response calibration curve will be useful for medical triage of the public and radiologic staff accidentally exposed to radiation during medical procedures or in the event of nuclear accidents.

Background Patient-reported allergies (PRAs) have been identified as a risk factor for worse outcomes and less satisfaction in patients undergoing knee and hip arthroplasty. Similar associations have not been elucidated in shoulder arthroplasty patients; however, previous research is sparse. The purpose of this study was to assess the outcomes following shoulder arthroplasty surgery with respect to patient-reported drug allergies. It was hypothesized that a higher number of allergies would be associated with worse patient-reported outcomes (PROs) following shoulder arthroplasty surgery. Methods Consecutive patients aged 18-89 years at the time of surgery who underwent primary shoulder arthroplasty between October 2005 and March 2018 performed by a single surgeon and had a minimum follow-up period of 1 year were reviewed. PRO scores, including the American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score, and 12-Item Short Form Health Survey Physical Component Summary and Mental Component Summary scores, as well as patient satisfaction, were collected preoperatively and postoperatively. Early clinical failures were reported. Subjects were categorized into a 3-level factor based on the number of PRAs (0, 1, or ≥2), and bivariate comparisons of mean postoperative PRO scores were performed using Kruskal-Wallis analyses. Additionally, multivariate regression was performed to assess the effect of PRAs on PROs while controlling for age, sex, arthroplasty type, baseline PRO scores, and Charlson Comorbidity Index. Results Overall, 411 shoulders were included in the final study population (367 patients, 44 of whom were treated bilaterally). The population was predominately male patients (n = 265, 64.5%), and the median age at the time of surgery was 66.5 years (first quartile–third quartile, 61.3-71.4 years). Of the patients, 253 (61.6%) underwent total shoulder arthroplasty (TSA) whereas 158 (38.4%) underwent reverse TSA. Five patients (2 TSA and 3 reverse TSA patients) experienced early clinical failure and required revision surgery. Minimum 1-year PROs were obtained for 345 of 406 patients (85.0%) with a mean follow-up period of 1.9 ± 1.2 years. Nearly all postoperative PROs reflected a trend of worse outcomes with more preoperative PRAs; however, the QuickDASH score was the only score showing a significant difference between allergy groups (P = .004). Pair-wise comparison using Nemenyi post hoc testing showed that the QuickDASH score was significantly higher (worse outcomes) for the group with ≥2 allergies compared with the group with 0 allergies. PRA was found to be a statistically significant predictor of higher postoperative QuickDASH scores (P = .043) and was more influential than the Charlson Comorbidity Index and sex. Additionally, PRA was the only statistically significant predictor of patient satisfaction (P = .016). Conclusion An increasing number of preoperative PRAs is associated with worse PROs and patient satisfaction following shoulder arthroplasty. The number of PRAs was the most influential predictor of patient satisfaction.

INTRODUCTION PARAGRAPHMultiple large COVID-19 genome-wide association studies (GWAS) have identified reproducible genetic associations indicating that some infection susceptibility and severity risk is heritable.1-5 Most of these studies ascertained COVID-19 cases in medical clinics and hospitals, which can lead to an overrepresentation of cases with severe outcomes, such as hospitalization, intensive care unit admission, or ventilation. Here, we demonstrate the utility and validity of deep phenotyping with self-reported outcomes in a population with a large proportion of mild and subclinical cases. Using these data, we defined eight different phenotypes related to COVID-19 outcomes: four that align with previously studied COVID-19 definitions and four novel definitions that focus on susceptibility given exposure, mild clinical manifestations, and an aggregate score of symptom severity. We assessed replication of 13 previously identified COVID-19 genetic associations with all eight phenotypes and found distinct patterns of association, most notably related to the chr3/SLC6A20/LZTFL1 and chr9/ABO regions. We then performed a discovery GWAS, which suggested some novel phenotypes may better capture protective associations and also identified a novel association in chr11/GALNT18 that reproduced in two fully independent populations.

Lack of public support for coastal adaptation can present significant barriers for implementation. In response, policy makers and academics are seeking strategies to build public support for coastal adaptation, which requires a deeper understanding of peoples’ preferences for coastal adaptation and what motives those preferences. Here, we conduct a systematic literature review to understand preferences for coastal adaptation options and the factors influencing these preferences. Ninety peer-reviewed publications meet the inclusion criteria. The findings revealed that hard protection options were often the most frequently preferred, likely due to a desire to maintain current shoreline, for the protection of recreational spaces and private property, and a perceived effectiveness of hard protection options. Soft protection, including nature-based approaches, accommodation, and no action were the next most preferred options. Finally, retreat options were the least preferred, often due to strong place attachment. We identify twenty-eight factors that could influence preferences, with risk perception, place attachment, and financial considerations occurring most frequently in the literature. In the conclusion, we outline the most significant research gaps identified from our analysis and discuss the implication for adaptation research and practice.

Background: When comprehensive arthroscopic management (CAM) for glenohumeral osteoarthritis fails, total shoulder arthroplasty (TSA) may be needed, and it remains unknown whether previous CAM adversely affects outcomes after subsequent TSA. Purpose: To compare the outcomes of patients with glenohumeral osteoarthritis who underwent TSA as a primary procedure with those who underwent TSA after CAM (CAM-TSA). Study Design: Cohort study; Level of evidence, 3. Methods: Patients younger than 70 years who underwent primary TSA or CAM-TSA and were at least 2 years postoperative were included. A total of 21 patients who underwent CAM-TSA were matched to 42 patients who underwent primary TSA by age, sex, and grade of osteoarthritis. Intraoperative blood loss and surgical time were assessed. Patient-reported outcome (PRO) scores were collected preoperatively and at final follow-up including the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), shortened version of Disabilities of the Arm, Shoulder and Hand (QuickDASH), 12-Item Short Form Health Survey Physical Component Summary (SF-12 PCS), visual analog scale, and patient satisfaction. Revision arthroplasty was defined as failure. Results: Of 63 patients, 56 of them (19 CAM-TSA and 37 primary TSA; 88.9%) were available for follow-up. There were 16 female (28.6%) and 40 male (71.4%) patients with a mean age of 57.8 years (range, 38.8-66.7 years). There were no significant differences in intraoperative blood loss ( P > .999) or surgical time ( P = .127) between the groups. There were 4 patients (7.1%) who had failure, and failure rates did not differ significantly between the CAM-TSA (5.3%; n = 1) and primary TSA (8.1%; n = 3) groups ( P > .999). Additionally, 2 patients underwent revision arthroplasty because of trauma. A total of 50 patients who did not experience failure (17 CAM-TSA and 33 primary TSA) completed PRO measures at a mean follow-up of 4.8 years (range, 2.0-11.5 years), with no significant difference between the CAM-TSA (4.4 years [range, 2.1-10.5 years]) and primary TSA (5.0 years [range, 2.0-11.5 years]) groups ( P = .164). Both groups improved significantly from preoperatively to postoperatively in all PRO scores ( P < .05). No significant differences in any median PRO scores between the CAM-TSA and primary TSA groups, respectively, were seen at final follow-up: ASES: 89.9 (interquartile range [IQR], 74.9-96.6) versus 94.1 (IQR, 74.9-98.3) ( P = .545); SANE: 84.0 (IQR, 74.0-94.0) versus 91.5 (IQR, 75.3-99.0) ( P = .246); QuickDASH: 9.0 (IQR, 3.4-27.3) versus 9.0 (IQR, 5.1-18.1) ( P = .921); SF-12 PCS: 53.8 (IQR, 50.1-57.1) versus 49.3 (IQR, 41.2-56.5) ( P = .065); and patient satisfaction: 9.5 (IQR, 7.3-10.0) versus 9.0 (IQR, 5.3-10.0) ( P = .308). Conclusion: Patients with severe glenohumeral osteoarthritis who failed previous CAM benefited similarly from TSA compared with patients who opted directly for TSA.

The condition of coastal areas around the world continues to decline despite over 50 years of integrated coastal management efforts. A myriad of institutional instruments such as legislation, policies and plans influence decisions made in the coastal zone. Despite this, there is limited comprehensive analysis of the degree to which institutional arrangements are focused on coastal issues and able to progress coastal management objectives. To address this gap we developed and applied an intentionality and substantiality framework to analyse 92 instruments with a role in coastal management at State, regional and local scales in Australia. We found that: (i) threats to Australia's coast are not adequately identified or managed via institutional instruments; (ii) institutional instruments do not make a contribution to coastal management unless intentionally designed to do so; and (iii) even in the presence of intention, comprehensiveness in the proposed actions is limited. The lack of comprehensive action is particularly evident in instruments operating at the local scale. Consequently, a reliance on local scale support to meet coastal management objectives in isolation is misplaced. While some States have recently implemented coastal reforms, the findings show that the decline in coastal condition is unlikely to be comprehensively addressed through current institutional arrangements.

The purposes of this study were to assess clinical and radiographic outcomes of arthroscopically-assisted, anatomic coracoclavicular ligament reconstruction using tendon allograft (AA-ACCR) for the treatment of Rockwood type III-V injuries at minimum 2-year follow-up and to perform subgroup analyses of clinical and radiographic outcomes for acute versus chronic and type III versus type IV-V injuries.In this retrospective study of prospectively collected data, patients who underwent primary AA-ACCR for the treatment of type III-V dislocations and had minimum 2-year follow-up were included. Preoperative and postoperative patient-reported outcome scores (PROs) were collected, including American Shoulder and Elbow Surgeons score, Single Numeric Assessment Evaluation score, Short Form-12 Physical Component Summary, Quick Disabilities of the Arm Shoulder and Hand score, and patient satisfaction. Preoperative and postoperative coracoclavicular distance (CCD) was obtained. PROs and CCD were reported for the total cohort and for the subgroups. Complication and revision rates were demonstrated.In total, 102 patients (10 women, 92 men) with a mean age of 45.0 years (range, 18-73 years) were included. There were 13 complications (12.7%) resulting in revision surgery. After exclusion of revised patients, PROs were available for 69 (77.5%). At mean follow-up of 4.7 years (range, 2.0-12.8 years), all PROs improved significantly (P.001). Median patient satisfaction was 9.0 (interquartile range, 8.0-10.0). Median preoperative to postoperative CCD decreased significantly (P.001). Subgroup analyses revealed significant improvements in all PROs and CCD from preoperative to postoperative for both acute and chronic, and type III and type IV-V dislocations (P.05) with no significant differences in postoperative PROs and satisfaction between (P.05).AA-ACCR for high-grade acromioclavicular joint injuries resulted in high postoperative PROs and patient satisfaction with significant improvements from before to after surgery in those who did not undergo revision surgery. Furthermore, subgroup analyses revealed that acute and chronic, and type III and type IV-V injuries benefitted similarly from AA-ACCR.Level IV; therapeutic case series.

Energy usage in buildings is coming increasingly under the spotlight as carbon policy focus shifts towards the utilization of thermal energy. In the UK, heating and hot water accounts for around 40% of energy consumption and 20% of greenhouse gas emissions. Heating is typically produced onsite, making widescale carbon or energetic improvements challenging. District heating networks (DHNs) can offer significant carbon reduction for many users but can only be implemented if the end user buildings have good thermal energy efficiency. This greatly limits the ability to implement advancing 4th and 5th generation DHNs, which are the most advanced systems available. We elucidate the current state of thermal efficiency in buildings in the UK and provide recommendations for necessary building requirements and modifications in order to accommodate 4th and 5th generation district heating. We conclude that key sectors must be addressed including creating a skilled workforce, producing relevant metrics and benchmarks, and providing financial support for early stage design exploration.

OBJECTIVES To evaluate the relationship between timing of definitive fixation, injury severity, and the development of systemic complications in severely injured patients with pelvic ring injuries. DESIGN Retrospective review. SETTINGS Level 1 trauma center. PATIENTS One hundred eighteen severely injured [Injury Severity Score (ISS) ≥ 16] adult patients with pelvic ring injuries undergoing definitive fixation, excluding patients treated with external fixation for hemodynamic instability. INTERVENTION Early fixation (≤36 hours) in 37 patients and delayed fixation (>36 hours) in 81 patients. MAIN OUTCOME MEASUREMENTS Systemic complications (acute respiratory distress syndrome, pulmonary embolism, deep venous thrombosis, sepsis, multi-organ failure, and death). RESULTS The delayed fixation group had a higher ISS and had more patients with chest injuries. There was no detectable difference in the number of patients with systemic complications between early versus delayed fixation groups [8 (22%) vs. 29 (35%), P = 0.1]. The only difference detected in specific complications was a higher incidence of pneumonia with delayed fixation [16 (20%) vs. 0 (0%), P = 0.004] with 11 of the 16 cases being associated with chest injury. Univariate analysis showed an association between complication and time to fixation, ISS, Glasgow Coma Scale, pH, base excess, and injuries to the head, chest, and abdomen. On multivariate analysis, only ISS remained significantly associated with the development of complications [Odds ratio 2.6 per 10 point increase, 95% confidence interval (CI), 1.4-4.4]. CONCLUSIONS These data suggest that the severity of injury is most highly associated with systemic complications after definitive fixation of pelvic ring injuries. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cas-mediated genome editing has enabled researchers to perform mutagenesis experiments with relative ease. Effective genome editing requires tools for guide RNA selection, off-target prediction, and genotyping assay design. While independent tools exist for these functions, there is still a need for a comprehensive platform to design, view, evaluate, store, and catalogue guides and their associated primers. The Finding Optimizing and Reporting Cas Targets (FORCAST) application integrates existing open source tools such as JBrowse, Primer3, BLAST, bwa, and Silica to create a complete allele design and quality assurance pipeline. FORCAST is a fully integrated software that allows researchers performing Cas-mediated genome editing to generate, visualize, store, and share information related to guides and their associated experimental parameters. It is available from a public GitHub repository and as a Docker image, for ease of installation and portability.

Anterior labroligamentous periosteal sleeve avulsions represent a diagnostic and treatment challenge. They are associated with a higher number of preoperative dislocations, as well as longer chronicity, and commonly result in a scarred and medialized labrum and periosteal sleeve complex. Anterior labroligamentous periosteal sleeve avulsion lesions therefore may be commonly overlooked. The complexity of the injury pattern has been associated with double the failure rate of standard Bankart lesions after arthroscopic repair. The purpose of this article is to describe our preferred arthroscopic technique for achieving full mobilization of the labral-periosteal complex and restore it to its anatomic location using a knotless, all-suture anchor construct.

CReSCENTCanceR Single Cell ExpressioN Toolkit (https://crescent.cloud), is an intuitive and scalable web portal incorporating a containerized pipeline execution engine for standardized analysis of single-cell RNA sequencing (scRNA-seq) data. While scRNA-seq data for tumour specimens are readily generated, subsequent analysis requires high-performance computing infrastructure and user expertise to build analysis pipelines and tailor interpretation for cancer biology. CReSCENT uses public data sets and preconfigured pipelines that are accessible to computational biology non-experts and are user-editable to allow optimization, comparison, and reanalysis for specific experiments. Users can also upload their own scRNA-seq data for analysis and results can be kept private or shared with other users.

Several techniques have been described for bone block augmentation as a treatment for posterior shoulder instability, including intra-articular distal tibial allograft and extra-articular iliac crest autograft. Although indications are not yet well defined, these bone augmentation procedures are considered in patients with glenoid bone loss, increased glenoid retroversion, previous failed posterior soft-tissue repair, and insufficient posterior capsulolabral tissue. In patients with posterior glenoid bone loss, the senior author (P.J.M.) recommends intra-articular glenoid reconstruction with a fresh distal tibial osteoarticular allograft. In patients with insufficient posterior capsulolabral tissue, the senior author prefers an extra-articular iliac crest autograft to buttress the posterior soft-tissue restraints. This technique guide outlines extra-articular iliac crest autograft treatment for recurrent posterior shoulder instability in patients with insufficient posterior soft tissues due to prior failed surgery. After an open capsulolabral repair is performed using suture anchors, the bone block is placed extra-articularly on the posterior glenoid neck.

INTRODUCTION: Acute Flaccid Myelitis (AFM) is a recently recognized, polio-like illness of children that can be functionally devastating. Severe cases can lead to ventilatory failure. Incomplete phrenic nerve injuries in other populations has been shown to respond to diaphragmatic stimulation. We therefore proposed an early assessment for incomplete denervation by laparoscopic direct stimulation of the diaphragm and placement of a diaphragmatic pacing system to enhance diaphragm function. CASE PRESENTATION: A 3 year-old girl presented with AFM with clinically and electrodiagnostically severe involvement of all four limbs and muscles of respiration. Direct stimulation of the diaphragm demonstrated contraction and a diaphragmatic stimulator was placed at 3 weeks post presentation. The patient was immediately able to tolerate short bouts of reduced ventilation settings. Electromyography via the pacing wires demonstrated intact motor units consistent with partial denervation/reinnervation in the left hemidiaphragm, and no motor units in the right hemidiaphragm. At three months, she tolerated 6 h of pacing on pressure support setting. At 5 months she demonstrated larger tidal volumes with active pacing than without. DISCUSSION: In our experience, AFM patients who require chronic ventilator support are rarely able to be weaned. Despite clinical and surface electrodiagnostic evidence of complete phrenic nerve involvement, the patient’s diaphragm responded to direct stimulation. The patient preferred pacing over non-pacing times and showed improved ventilatory ability with pacing as opposed to without, though remains ventilator-dependent. These findings support augmentation of diaphragm function and possible enhanced recovery of spontaneous function.

Background The increasing use of genome sequencing with patients raises a critical communication challenge: return of secondary findings. While the issue of what sequencing results should be returned to patients has been examined, much less attention has been paid to developing strategies to return these results in ways that meet patients' needs and preferences. To address this, we investigated delivery preferences (i.e., who, how, when) for individual genome sequencing results among women diagnosed with breast cancer at age 40 or younger. Methods We conducted 60 semistructured, in‐person individual interviews to examine preferences for the return of different types of genome sequencing results and the reasons underlying these preferences. Two coders independently coded interview transcripts; analysis was conducted using NVivo 10. Results The major findings from the study were that: (1) many participants wanted sequencing results as soon as possible, even at the time of breast cancer diagnosis; (2) participants wanted an opportunity for an in‐person discussion of results; and (3) they put less emphasis on the type of person delivering results than on the knowledge and communicative skills of that person. Participants also emphasized the importance of a results return process tailored to a patient's individual circumstances and one that she has a voice in determining. Conclusions A critical goal for future transdisciplinary research including clinicians, patients, and communication researchers may be to develop decision‐making processes to help patients make decisions about how they would like various sequencing results returned., While the issue of what genome sequencing results should be returned to patients has been examined, much less attention has been paid to developing strategies to return these results in ways that meet patients' needs and preferences. To address this, we investigated delivery preferences (i.e., who, how, when) for individual genome sequencing results among women diagnosed with breast cancer at age 40 or younger. The major findings from the study were that: (1) many participants wanted sequencing results as soon as possible, even at the time of breast cancer diagnosis; (2) participants wanted an opportunity for an in‐person discussion of results; and (3) they put less emphasis on the type of person delivering results than on the knowledge and communicative skills of that person.

In Australia, shared responsibility is a concept advocated to promote collective climate change adaptation by multiple actors and institutions. However, a shared response is often promoted in the absence of information regarding actions currently taken; in particular, there is limited knowledge regarding action occurring at the household scale. To address this gap, we examine household actions taken to address climate change and associated hazards in two Australian coastal communities. Mixed methods research is conducted to answer three questions: (1) what actions are currently taken (mitigation, actions to lobby for change or adaptation to climate impacts)? (2) why are these actions taken (e.g. are they consistent with capacity, experience, perceptions of risk); and (3) what are the implications for adaptation? We find that households are predominantly mitigating greenhouse gas emissions and that impact orientated adaptive actions are limited. Coping strategies are considered sufficient to mange climate risks, proving a disincentive for additional adaptive action. Influencing factors differ, but generally, risk perception and climate change belief are associated with action. However, the likelihood of more action is a function of homeownership and a tendency to plan ahead. Addressing factors that support or constrain household adaptive decision-making and action, from the physical (e.g. homeownership) to the social (e.g. skills in planning and a culture of adapting to change) will be critical in increasing household participation in adaptation.

Insulin-dependent individuals with diabetes are at risk for a severe hypoglycemic event that may predispose them to several repeat episodes during which the normal counter regulatory mechanisms that protect against hypoglycemia fail to be activated. This state of hypoglycemia unawareness is characterized by a failure of glucagon release, preventing mobilization of endogenous glucose stores from the liver. We describe the discovery of a novel hormone, produced in pancreatic delta cells, which stimulates glucagon production and release, particularly under low glucose conditions. We hypothesize that this hormone, called neuronostatin, may be effective as a co-therapy with insulin to prevent repeated, potentially fatal episodes of recurrent hypoglycemia.

Genetic test results have medical implications beyond the patient that extend to biological family members. We examined psychosocial and clinical factors associated with communication of genetic test results within families. Women (N = 1080) diagnosed with breast cancer at age 40 or younger completed an online survey; 920 women that reported prior cancer genetic testing were included in analysis. We examined the proportion of immediate family members to whom they communicated genetic test results, and built multivariable regression models to examine clinical and psychosocial variables associated with the proportion score. Participants were most likely to communicate test results to their mother (83 %) and least likely to their son (45 %). Participants who carried a BRCA mutation (OR = 1.34; 95 % CI = 1.06, 1.70), had higher interest in genomic information (OR = 1.55; 95 % CI = 1.26, 1.91) and lower genetic worry (OR = 0.91; 95 % CI = 0.86, 0.96) communicated genetic test results to a greater proportion of their immediate family members. Participants with a BRCA1/2 mutation shared their genetic test results with more male family members (OR = 1.72; 95 % CI = 1.02, 2.89). Our findings suggest that patients with high worry about genetic risks, low interest in genomic information, or receive a negative genetic test result will likely need additional support to encourage family communication.

This paper presents empirical data on household perceptions of capability to adapt to climate hazards and associated capacity needs. Households play an important role in responding to the impact of a changing climate by creating a functional link between individual and community responses to change. However, household perspectives on their capacity needs are rarely sought in programs seeking to provide incentives for household action—despite the influence of normative values and perceptions on household action. Rather, interventions are often informed by quantitative measures of adaptive capacity, such as access to financial or social capital. An alternative approach involves analysis of social narratives of capability that reflect normative perceptions of climate risk and capacity needs. Implementation of this approach reveals that a significant number of households in vulnerable locations consider existing capacities sufficient to manage familiar climate hazards, regardless of socio-economic circumstance. Our comparative study of two Australian coastal communities also suggests that a dominant narrative of capability to manage climate hazards reduces the likelihood of household investments in adaptive actions. While socio-political influences on narratives are often deeply embedded and difficult to change in the short term, identifying perceived risk and response capacity is pivotal in determining the likely utility of adaptive capacity stocks as measured through quantitative means.

The increasing importance of genomic information in clinical care heightens the need to examine how individuals understand, value, and communicate about this information. Based on a conceptual framework of genomics-related health literacy, we examined whether health literacy was related to knowledge, self-efficacy, and perceived importance of genetics and family health history (FHH) and communication about FHH in a medically underserved population. The analytic sample was composed of 624 patients at a primary care clinic in a large urban hospital. About half of the participants (47%) had limited health literacy; 55% had no education beyond high school, and 58% were Black. In multivariable models, limited health literacy was associated with lower genetic knowledge (β = -0.55, SE = 0.10, p < .0001), lower awareness of FHH (odds ratio [OR] = 0.50, 95% confidence interval [CI; 0.28, 0.90], p = .020), and greater perceived importance of genetic information (OR = 1.95, 95% CI [1.27, 3.00], p = .0022) but lower perceived importance of FHH information (OR = 0.47, 95% CI [0.26, 0.86], p = .013) and more frequent communication with a doctor about FHH (OR = 2.02, 95% CI [1.27, 3.23], p = .0032). The findings highlight the importance of considering domains of genomics-related health literacy (e.g., knowledge, oral literacy) in developing educational strategies for genomic information. Health literacy research is essential to avoid increasing disparities in information and health outcomes as genomic information reaches more patients.

Highlights • Glenohumeral cartilage T2 values were correlated to increasing rotator cuff pathology severity. • Massive tear versus lesser injury differences were most evident in superior humeral cartilage. • Sagittal T2 mapping best captures superior humeral head cartilage change in massive tear patients., Purpose To examine the relationship between glenohumeral cartilage T2 mapping values and rotator cuff pathology. Method Fifty-nine subjects (age 48.2 ± 13.5 years, 15 asymptomatic volunteers and 10 tendinosis, 13 partial-thickness tear, 8 full-thickness tear, and 13 massive tear patients) underwent glenohumeral cartilage T2 mapping. The humeral head cartilage was segmented in the sagittal and coronal planes. The glenoid cartilage was segmented in the coronal plane. Group means for each region were calculated and compared between the groups. Results Massive tear group T2 values were significantly higher than the asymptomatic group values for the humeral head cartilage included in the sagittal (45 ± 7 versus 32 ± 4 ms, p

Background Coracoid transfer procedures have been increasingly utilized for anterior shoulder instability with associated glenoid bone loss1. Unfortunately, in a young, high-risk patient population, these procedures can fail secondary to traumatic causes but also because of bone graft resorption or malposition or hardware prominence, among other reasons2. In active patients, revision glenoid reconstruction may be indicated. Distal tibial osteoarticular allografts have been utilized to treat recurrent anterior shoulder instability for several years3. Recently, this technique has been applied to cases of failed Latarjet procedures in order to reconstitute the absent glenoid bone stock4, demonstrating excellent clinical outcomes at a minimum follow-up of 3 years2. Description The procedure is performed in the beach-chair position. First, a diagnostic shoulder arthroscopy is performed to assess the cartilaginous surfaces, to examine the Hill-Sachs lesion and its engagement, and to remove any loose bodies. Next, the prior deltopectoral incision is developed, and the deltopectoral interval is utilized to visualize the subscapularis. The subscapularis is split at the junction of its upper two-thirds and lower one-third. Careful dissection is used to develop the subscapularis split from lateral to medial because the prior coracoid transfer affects the native neurovascular anatomy medially. If substantial coracoid bone remains from the previous transfer, a conjoined tendon tenotomy can be performed to further aid in visualization5. Next, any associated hardware is removed, and the coracoid bone remnant is removed. The glenoid defect is sized, and the osseous glenoid bed is prepared. A fresh-frozen distal tibial allograft is then fashioned, washed of marrow elements, and enhanced with platelet-rich plasma before being fixed to the glenoid with use of 2 cortical screws in a lagged fashion. The capsule and subscapularis split are then closed to complete the repair. Alternatives Alternatives to revision glenoid reconstruction with distal tibial allograft include reconstruction with an iliac crest autograft, distal clavicular autograft, revision coracoid transfer, or nonoperative treatment through rehabilitation and activity modification. Rationale In cases of failed coracoid transfer for anterior shoulder instability with associated glenoid bone loss, distal tibial allograft is the superior revision treatment option for several reasons: it allows for an osteoarticular graft, offers flexibility in terms of graft size, and requires no donor-site morbidity. Distal tibial allograft allows active, high-risk patients to have restored and maintained stability with low complication and graft-resorption rates2. Expected outcomes Glenoid reconstruction with a distal tibial allograft is associated with improved patient-reported outcomes from preoperatively, as well as recurrence rates of 90%2. Important tips Initiating the procedure with an arthroscopic evaluation allows for a complete diagnostic examination, including the Hill-Sachs lesion, articular cartilage, and rotator cuff, as well as removal of any loose bodies, which are frequently present and sometimes difficult to visualize and access during the open procedure.A subscapularis split allows for maintenance of the subscapularis insertion on the lesser tuberosity as well as minimal disruption of the muscle fibers.A conjoined tendon tenotomy can provide improved access for hardware removal if the coracoid bone graft from the prior transferred coracoid is present.A 5.5-mm arthroscopic burr is utilized to decorticate the anterior aspect of the glenoid, which facilitates graft union because the burr allows built-in suction capability during constant irrigation, minimizing the possibility of heat necrosis.The distal tibial allograft is thoroughly lavaged to remove residual marrow elements prior to insertion in order to diminish potential immunogenicity.Two solid, fully threaded 3.5-mm cortical screws are placed in a lagged fashion to fix the distal tibial allograft to the glenoid.

The Middle Pennsylvanian Herrin and Springfield coals contain the majority of the Illinois basin’s resources. Many mining issues of these two seams are directly related to the geology of the region, including regional stress, faulting, and facies changes. Some of these conditions are widespread, while others are locally restricted. The long history of mining in these seams has been associated with many difficulties and hard-learned lessons related to mining geology especially concerning aspects of coal quality and roof geology along paleochannels, moisture-sensitivity in shales, fractures and “slips” in shales, floor heave, lateral stresses, clay dikes (veins), and coal balls. Both seams occur within classic “cyclothems,” resulting from sequences of deposition between lowstand and highstand deposition. Transgressive, marine black shales and limestones blanket the coals across much of the basin, except near syndepositional channels where wedges of gray silty shale and interbedded shale and sandstone intervene between the coal and transgressive shale. Differences in the thickness, chemistry and strength of various shales in each sequence influence coal quality and roof conditions in underground mines. Associations of mining geology issues not specifically related to tectonics and horizontal stress, are (1) syndepositional channel and channel margin conditions, (2) post-depositional channels, (3) gray-shale wedge margins, and (4) marine shale roofs; especially where limestones thicken. Many of these features are similar to both seams, while others are more common in the Herrin, than Springfield Coal. Similar conditions occur above other coal beds in the Illinois Basin, as well as coal-bearing strata in other basins. Herein we review horizontal stress, fractures, coal quality, partings, coal balls, clay dikes (veins), dips and swales, floor heave, moisture sensitivity in shales, shale rolls, limestone bosses and cutouts, paleochannels and cutouts, stackrock conditions, paleoslumps, coal riders, kettlebottoms, and concretions in the roof. Hopefully, this summary will be useful for understanding seams with similar geology, but with less research on mining geology or shorter mining histories.